Current Thinking of the Osteochondroses. Diego Jaramillo, M.D., M.P.H. Department of Radiology Stanford Children s Hospital

Transcription

1 Current Thinking of the Osteochondroses Diego Jaramillo, M.D., M.P.H. Department of Radiology Stanford Children s Hospital

2 What is an osteochondrosis? Abnormal endochondral ossification and epiphyseal growth of epiphysis, apophyisis, or round bone Delayed Ossification Vulnerable Vascular Supply (vascular canals) Increased Activity Decreased Bone Production AVN

3 Axial Skeleton Scheuermann disease Upper extremity Panner Kienbock Lower extremity Legg-Calve-Perthes Sinding-Larsen-Johansson Osgood-Schlatter Blount Sever Kohler Freiberg

4 Osteochondroses- Stages necrosis of bone and cartilage revascularization granulation tissue invasion osteoclastic resorption of necrotic segments osteoid replacement formation of mature lamellar bone

5 Osteochondroses- Stages Histology 1. necrosis of bone and cartilage 2. revascularization 3. granulation tissue invasion 4. osteoclastic resorption of necrotic segments 5. osteoid replacement 6. formation of mature lamellar bone MRI 1. Lack of enhancement Loss of marrow fat signal 2. New enhancement (transphyseal?) 3. Fragmentation and collapse 4. Healing

6 Osteochondrosis of the Capitellum: Panner Disease children <10 years Hx of throwing XR: fragmentation, sclerosis of capitellum MRI: low SI on T1-and high SI on T2 intact articular cartilage

7 Panner Disease Tx: rest, antiinflammatories normal capitellar growth resumes without longterm sequelae

8 Osteochondrosis of the Lunate Kienböck s Disease AVN of entire lunate 20 to 40 years of age Manual labor 75%: negative ulnar variance

9 Osteochondrosis of Vertebral Ring Apophyiss Scheuermann Disease

10 5 year-old boy with limping and pain in the right hip for the last 4 weeks

11

12 Legg Calve Perthes Disease- DWI Increased ADC with AVN ADC remains elevated until disease heals

13

14 13-year-old boy with knee pain

15 Osgood-Schlatter Disease Stress injury in the tibial tubercle Transition from fibrocartilage to hyaline cartilage Changes in soft tissues>> ossification irregularity

16

17 Sinding-Larsen-Johansson Disease

18 Sress to the medial compatment of knee Epiphyseal and physeal changes in the tibia and femur Medial meniscal hypertrophy Blount Disease

19

20 10-year-old girl with heel pain

21

22 Sever s Disease 9-11 years of age Activity XR not diagnostic MRI: edema Calcaneal apophysis Metaphyseal equivalent Surrounding soft tissues Tendon thickening

23 5-year-old girl with midfoot pain

24

25

26

27 Köhler s Disease Osteonecrosis of tarsal navicular Sclerosis and fragmentation can be normal Compared to normal variant, disease affects older children and is painful

28 Kingsborough 7 y/o boy 4-05

29 Kingsborough 7 y/o boy 4-05 T1 (not T2 images were obtained)

30 15-year-old girl with pain in the forefoot

31

32 Freiberg s Disease Second or third metatarsal head osteonecrosis Repeated trauma More common in women Association with high heels

33

34 Does it make sense to talk about Osteochondrosis? Most are descriptions based on findings from early radiographic era A category makes sense if it enhances understanding or facilitates remembering

35 Etiology Trauma Scheuermann Panner Kienboch Sinding-Larsen-Johannson Osgood-Schlatter Blount Sever Freiberg Osteonecrosis Panner Kienboch Legg-Calve-Perthes Kohler Freiberg

36 Radiographs: Fragmentation and Increased Density Can be normal Inferior patellar pole (Sinding-Larsen-Johannson) Tibial tubercle (Osgood-Schlatter) Calcaneal apophysis (Sever) Tarsal navicular (Kohler) Always pathologic Vertebral endplate (Scheuermann) Capitellum (Panner) Proximal femur (Legg-Calve- Perthes) * Proximal tibia (Blount) Lunate (Kienboch) Metatarsal (Freiberg)

37 MRI: Cartilage abnormality All except Kienboch and Freiberg Decreased enhancement Panner Kienboch Legg-Calve-Perthes Kohler Freiberg

38 Take Home Points Tendency to move away from Osteochondrosis MRI: Soft tissue edema Cartilaginous abnormalities Decreased enhancement (in some)